New advice and guidance (A&G) requirements will cause cost pressures for GP practices due to a ‘significant increase in unfunded workload’, a large group of LMCs has warned.
Berkshire, Buckinghamshire and Oxfordshire (BBO) LMCs has published its own analysis of the imposed 2026/27 GP contract, warning that practices are ‘certainly in a worse position in real terms than they were in April 2024’.
The document, first seen by our sister publication Pulse, provides an analysis of the financial implications of the latest contract (see box below), which it said is based ‘on communication and discussion with LMC colleagues around the country’, and ‘scrutiny of draft documents where these are readily available’.
The contract embedded the A&G enhanced service worth £80m within core practice funding and introduced a requirement for GPs to use A&G across specialities ‘prior to or in place of a planned care referral where clinically appropriate’.
The profession has raised concerns about patient safety as a result of the move, with the BMA threatening collective action over it.
Although there had also been worries that a national target was set for referrals being sent back to general practice, last week NHS England wrote to GPs to confirm this was not the case.
The letter signed by Dr Amanda Doyle, national director for primary care and community services, acknowledged that there had been concerns about ‘terminology’ in the recent published neighbourhood health framework, which said the Government is aiming for 25% of GP referrals to be ‘diverted’ back to GPs via amendments to advice and guidance (A&G) by 2027 for 10 ‘high volume specialties’.
Dr Doyle explained: ‘It is important to be clear that there is no national target for specialists, trusts or general practice to divert a fixed proportion of referrals away from hospital care. The objective is simply to identify the most appropriate next step for each patient, based on specialist assessment and triage at speciality or sub-specialty level.’
In response, BBO LMCs has said that despite the clarification from NHS England, the new A&G requirements will cause unfunded workload and cost pressures as a result.
Its own document said: ‘It is important to note that the movement of A&G into core represents a significant increase in unfunded workload, which will correlate to a resource expenditure upon practices necessitating a net reduction in overall funding availability.
‘The previous A&G enhanced service (ES) was valued at £20 per referral with payment capped at £80m nationally. As now the work is mandatory and will exceed this previous £80m cap, the cost implications of this workload should be quantified at least to the level of £20 per referral that existed under the ES, considering the argument that £20 was grossly insufficient for the workload involved.
‘Whilst expected volume is difficult to predict, an estimate can be made based on the Government’s own aspiration that “at least 25%” of referrals be “diverted” back to the GP with further instructions over the coming year.’
Although NHS England has since clarified the figure quoted relates ‘to an estimate of the potential proportion of patients’ who could be ‘appropriately assessed and supported by a specialist consultant without a hospital outpatient appointment’, BBO LMCs pointed out the same letter makes it clear that referrals will still be converted to A&G ‘where primary care management is clinically appropriate’.
Its analysis added: ‘In terms of quantifying this workload as a cost at practice level, the previous DES has been costed to be funded to “about half the level required per request.”
‘If this principle is applied to the “estimated” quarter of all referrals (5 million/year), then this gives an unfunded workload cost of £1.75 per patient.’
Summarising the expected impact of contract changes, BBO LMCs said that the ‘funding quantum’ makes the contract ‘de facto unviable for practices’.
According to its analysis, the ‘negative net position’ wipes out ‘just over 88%’ of the increased funding provided by the 2025/26 contract last year.
It concluded: ‘Workload is higher than ever before, and perversely is now contractually mandated and monitored, with contractual levers to performance manage practices who aren’t keeping up with this (infinite) demand.
‘We do not see how constituent contractor businesses can realistically survive in this hostile environment.’
BBO LMC’s analysis of 2026/27 GP contract
Headline uplifts per patient
Global Sum: £6.73
QOF: £0.39 per patient
SFE Uplifts: £0.11
PCN Uplifts: £0.24
ARRS Uplifts: £0.82
Total uplifts: £8.29
Workload losses
A&G recycle: -£1.25
A&G Additional Workload: -£1.75
Capacity & Access Loss: -£4.58
Weight Management ES Loss: -£0.19
QOF Losses: -£0.18
Total losses: £7.95
2026/27 Practice Bottom Line Position: £0.34 per patient
Real Terms (Inflation Adjusted) Practice Bottom Line Position: –£7.06 per patient
Source: BBO LMCs
A version of this article was first published by our sister title Pulse
